Breast Cancer Screening and SurgeryApril 26, 2018Ashley B. Simpson, DO

Objectives• Breast cancer screening

• Common breast complaints

• Surgical management of breast cancer

Breast Screening

Question 1

• At what age and frequency should women begin screening mammography?- A. Every 2 years at age 40- B. Every 2 years at age 50- C. Annually at age 40- D. Annually at age 50- E. none of the above

Introduction• Breast cancer is the leading form of cancer

in women.• In 2017 nearly 30% of cancers diagnosed

in women were breast cancers.• Since 1989 deaths from breast cancer have

steadily declined- screening mammography leading to earlier

detection

Who Should Be Screened?

Risk Stratification- How?Tyrer Cuzick Model

- Most useful model- Takes into account 1-3rd degree family members

with breast / ovarian cancer- Age of menarche and menopause, AFLB,

breastfeeding, BMI, previous biopsies of atypia, known BRCA mutations within the family

- Calculates lifetime risk, risk of a BRCA mutation

Woman's age is 40 years.Age at menarche was 14 years.Age at first birth was 30 years.Person is premenopausal.Height is 5 ft 5 ins.Weight is unknown.Woman has never used HRT.Woman has had hyperplasia without atypia.

Risk after 10 years is 8.474%.10 year population risk is 1.606%.Lifetime risk is 44.33%.Lifetime population risk is 9.736%.Probability of a BRCA1 gene is 0.062%.Probability of a BRCA2 gene is 2.292%.

? ?

?

60 ?

63

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40

40 50 60 70 80 0.0%

8.9%

17.8%

26.7%

35.6%

44.5%

Personal risk

Population risk

Risk Stratification- How?Gail Model

- Calculates 5 year risk- More limited- low sensitivity and specificity - Cannot be used to assess role for genetic testing- Women must be at least 35 to use this model

Average Risk• No personal history of biopsy proven atypia or cancer • No known genetic predisposition to cancer, • Less than 20% lifetime risk of cancer based on risk

models.

• Currently, regardless of the model used, there is no method for determining that a patient has a “low” risk patient for breast cancer.

Average Risk Recommendations• Breast self-awareness and clinical breast exam along

with digital mammography• Annual mammogram at age 40 • Begin clinical exam every three years before age 40

and annually after 40• Practice self breast awareness

Moderate Risk• Personal history of biopsy-proven atypia or lobular

carcinoma in situ (LCIS)- ADH 30% risk of developing breast cancer (NEJM)

• First-degree relatives with breast or ovarian cancer

• History of radiation to the chest wall before age 30

Moderate Risk Recommendations• Mammography ten years prior to the earliest first-

degree relative but not before age 25

• Begin screening 8 years after treatment for patients with chest radiation

• Magnetic Resonance Imaging (MRI) in addition to annual digital mammography screening

High Risk• High-risk women have a significantly increased lifetime

risk of developing breast cancer- > 20% lifetime risk

• Important to discuss all options available for reducing risk

• Lifetime risk is as high as 87% and the risk of ovarian cancer can be as high as 54% with a BRCA 1/2 gene mutation

High Risk Recommendations• Initial screening should begin with MRI at the age of 25

and mammogram at age 30.• Annual MRI until the age of 75• In women with a known BRCA mutation:

- Ovarian cancer screening- Consider risk reducing mastectomy- Consider risk reducing BSO

Which Test is the Right Test? • Mammogram

- Screening- Diagnostic

• Ultrasound

• MRI

• Other Modalities

Patient Education• Self Breast Awareness

- Optimal on days 7-15 of menstrual cycle - “Know Your Normal”

• Modifiable Risk Factors- Obesity- More than 1 alcoholic beverage / day- HRT- Nulliparous / AFLB > 30

Provider Education

• Annual clinical breast exams• Obtain detailed family history

- Type of cancer - Age of diagnosis- Include several generations

• Identify patients who may benefit from enhanced screening options

Common Breast Complaints

Question 2

• What percentage of patients who present with nipple discharge will have breast cancer?- A. 0.5%- B. 2%- C. 7%- D. 10%- E. 15%

Answer: B

• Roughly 2% of breast cancers present with nipple discharge.

Topics

• Nipple Discharge• Focal Pain• Skin Changes

Case 1

• LH is a 48 year old female presents with single duct brown discharge that is spontaneous

• No FH breast cancer. • Never had a mammogram• No risk factors for breast cancer

Nipple discharge

• Most common complaints• 50-80 % women have had some sort of

fluid • 5-7% referred to surgeons• Most common etiology is BENIGN

Nipple Discharge: Evaluation

• Goals: distinguish between benign or pathologic - Papilloma, cancer, high risk lesions

• History is most helpful: - Benign – bilateral, multiductal, occurs with

manipulation- Concerning – unilateral, uniductal,

spontaneous, bloody

Types of Discharge

• Lactational

• Physiologic

• Pathologic

Lactational Discharge• Postpartum discharge can last at least 6 months after

cessation of breastfeeding

• Bloody discharge can be seen in 20% of women during pregnancy and is usually benign (ductal hyperplasia)

• Bloody discharge seen in 15% of lactating women. Self-limiting, if not refer to a surgeon.

Physiologic Discharge• Non pathologic, Unrelated to pregnancy

or breastfeeding• Galactorrhea – milky discharge involving

multiple ducts bilaterally.- Neurogenic stimulation - Breast compression- Stresses affecting dopamine release

Physiologic Discharge

• Absence of Galactorrhea- Multiple ducts – elicited, bloody or non bloody,

bilateral, black or clear, green- Fibrocystic changes or ductal ectasia- Green nipple discharge is textbook for

fibrocystic changes (not molded milk!)- Reassurance

Duct Ectasia• Major subareolar ducts dilate during aging • Nipple discharge common • Scarring due to periductal inflammation

- most common cause of benign acquired nipple inversion

- On exam if nipple can be easily evertedthere is no malignancy

Medication List

Causes of Nipple Discharge

Pathologic Discharge

• Unilateral, single duct, persistent, spontaneous, associated with mass

• Serous, sanguinous, serosanguinous• Most common reason: papilloma

- (52-57%)• Papillomas may harbor atypia or DCIS• Malignancy in 5-15% pathologic discharge

Pathologic Discharge

• Age is predictive of cancer risk with nipple discharge

• <40 – 3%• 40-60 – 10%• >60 – 32%

Clinical evaluation

Evaluation

• History and Physical• Diagnostic Evaluation: Bilateral diagnostic

mammogram and retroareolar ultrasound• Referral to a surgeon: spontaneous,

unilateral, single duct discharge, bloody, or clear, or reassurance

• Cytologic examination not necessary

Intraductal papilloma

Case 1

• Patient underwent diagnostic imaging and retroareolar ultrasound that showed a retroareolar mass

• Minimally invasive biopsy showed an intraductal papilloma with atypia

• On excisional biopsy, the patient was shown to have DCIS

Case 2

• 52 year old with focal pain in the right upper inner quadrant breast

• Diagnostic mammogram (tomosynthesis) was negative

• CBE 1.5 cm mobile irregular mass in the upper inner quadrant breast

Diagnostic Mammogram

Ultrasound

Breast Pain• Cyclical

- hormonal changes with menstrual cycle- bilateral and more common in UOQ

• Noncyclical – unilateral- Pendulous breasts, diet/lifestyle- HRT, ductal ectasia, mastitis, breast cancer- hidradenitis suppurativa- pregnancy, trauma, cysts, medications

Evaluation• History and Physical• Focal pain with or without a mass

- diagnostic imaging • Most breast pain is benign

- 0.5-3.3% breast pain associated with cancer.

• Refer for any concern despite negative imaging

Evaluation

Case 2

• Patient underwent a minimally invasive biopsy that showed a malignancy

Skin Changes

• Nipple Areolar Eczema vs. Paget’s

• Infection vs. Inflammatory

• Sebaceous cyst vs. Malignancy

Eczema• Characterized by thickened skin,

increased skin markings (lichenification), and excoriated, fibrotic papules.

• Involvement of nipple may mimic Paget’s• Generally bilateral, possible systemic

Skin ChangesPaget's Nipple eczema

Paget’s Disease

Paget’s Disease of the Breast• Scaly, raw, vesicular, or ulcerated lesion

that begins on the nipple and then spreads to the areola

• Occasionally bloody discharge is present • Usually unilateral• Nipple retraction• Symptoms lasting months

- May have delay in diagnosis

Infection• Lactational: commonly seen in first

pregnancy and first 12 weeks of postpartum, weaning- Cracked nipple / skin abrasion – leading to

edema of ducts and poor milk drainage leading to increased number of organisms

- Sx: Pain, erythema, swelling, possible fluctuant mass

Lactational Infection• Management: antibiotics and breast feeding• Improvement usually seen in 48-72 hours• If a fluctuant mass – drain the abscess

- Needle aspiration• Reevaluate in 72 hours

Non-lactational Abscess• Central or periareolar infection• Common in Cigarette smokers (Zuska’s)

- damages the wall of the subareolar ducts• Causes periductal inflammation leading to

periductal mastitis • Short onset of central breast pain, mass,

possible nipple retraction, purulent nipple discharge

Management• Antibiotics and drainage• Encourage smoking cessation• Rule out inflammatory breast cancer if

persistent redness• Peripheral abscesses seen less common

and may assoc with DM, rheumatoid arthritis, steroids, trauma

Granulomatous Lobular Mastitis

• Non caseating granulomata and microabscesses.

• Causes: Autoimmune, sarcoidosis, Wegener's, arthritis, foreign body, TB, mycotic, parasitic, idiopathic,

• Firm mass – similar to malignancy

Inflammatory Breast Cancer

• Red, warm, slightly indurated, tender breast with peau d’orange appearance

• Dermal lymphatics containing tumor emboli

• Vascular congestion and tissue edema • Onset over weeks

Breast Infections• Quick onset, painful• Start abx, REEXAMINE in 72 hours• Ultrasound to evaluate for abscess• Alternative diagnoses such as

inflammatory breast cancer should also be considered

Surgical Management ofBreast Cancer

Question 3• Which statement is most accurate regarding

mastectomy compared to breast conservation therapy(BCT)?- A. Rate of recurrence for mastectomy is lower than

lumpectomy alone- B. There is no difference in overall survival with

mastectomy compared to BCT- C. Tumors with aggressive biology are best treated with

mastectomy- D. All of the above- E. A&B- F. A&C

Answer: E

• Long term data has proven partial mastectomy (lumpectomy) combined with whole breast radiation is equivalent to mastectomy to overall survival.

• Lumpectomy alone carries a ~40% risk of recurrence compaed to mastectomy (10%)

• Tumor biology alone should not direct surgical management

Historical Perspective

• NSABP- B-04- B-06

BCT vs Mastectomy?

BCT vs Mastectomy

Potential Contraindications• Collagen vascular disease

- Lupus, sclerodema

• Pregnancy (1st & 2nd trimester)

• Pacemakers

• History of previous breast/chest radiation

• Significantly compromised pulmonary / cardiac function

Tumor To Breast Ratio• Neoadjuvant chemo can be used to shrink

large tumors for patients who desire BCT- TNBC- HER2

Tumor to Breast Ratio• 20% breast tissue removal results in

deformity of the breast

• Oncoplastic surgery involves resection of the tumor with rearrangement of the breast tissue to correct deformity.

Oncoplastic Surgery

Oncoplastic Surgery- Wise Pattern

Multi Centric Breast Cancer• Synchronous tumors within different

quadrants• Significant deformity with BCT• Best served with mastectomy

Inflammatory Breast Cancer• Rare < 5% breast cancers• Aggressive• Neoadjuvant chemo• Modified radical mastectomy• PMRT

Surgical Options

BCT• Oncoplasty• APBI• IORT

Mastectomy• Nipple Sparing• Direct to implant• Autologous recon

Nipple Sparing Mastectomy

IORT

APBI Mammosite

Contralateral Prophylactic Mastectomy

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